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San:.Iaagllf n)CgIunty.Envlr6 irn0iA l.Wealth De.partlttent <br /> WELL&Boma PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS. A/6,b- ..led PERMIT SR#. - -- <br /> j <br /> i <br /> LICENSED CONTRACTORS DECLARATION (LCD) j <br /> =0`9khe. <br /> :affirm that I am.IicerlsscC v:n' ler the provisions of Ghap%r q (Camrriencirl` with Seofion 7.000) of <br /> >.alfgrnla Business arl Professions Gotle acid m :llcense is in:ful force:afid effect:. <br /> 0onse <br /> Dat l rci 12bt GontraGtor_ � +��`.�3 <br /> Signature, p ..7i (tie; - <br /> Print l larnet <br /> W0ikK#RS'C6MP9NSATI.6N..bECLA'"TION <br /> e3jafrre ` erapI her' p . Ws.:f71owIrg declarations (cilieck one). <br /> i <br /> __ . I have: and will mafniafri .a .certifipate.,of gorls�,nt Ao.self-Inst"re, ppn*orr; as <br /> provided iQt by Section 3700 of:the Labor Code; for the perfprmance..of the work for W1h this. <br /> r �.'perrnit%issued.. <br /> 1�' I have and will maintain workers' cornpansAtiw insurance, as required �y°Section X70.6 of the - <br /> Labor. Code, fob the pir► orttian60 of, the :work for Uhich tails permit is issued. My workers` <br /> rriperisatfor:irrsuraricte.cartier <br /> d'*;"l' r iurlbers are;. , { �- <br /> Carrier:j L Kofi.cy.[STttrribef:�„ �'� { `+ <br /> -- <br /> 1 Certify that In the performarice of he workfior which this permit is Issued, I shall nvt employ any <br /> :person in any msnner`so as tcf become subject-to the workers' compensatlan law of Galifornia, <br /> Grid aurae that if I should become-subject to Workers' Coi ll' erisatlon prov.sfons of Section-3766 of <br /> tl a tgbtir Code, I shall fottiiwrtli'Ccrirtply witt7 thtisp:pravislons. <br /> . otter 011261_41 <br /> i <br /> Print N,arnes C'. <br /> WARNINo:rwWRE ro sspuRE-1NOM. 110,Ci�t4IP SAMON P�WRAG Is;uNt.AYI�FUL,/WI}SHALL S[3k3JE 3 41F 1 MPLdY>*FI:TCJ <br /> O MINAI.?1=NALTdES iANd'CIVII.FINE$'t,P TQ;'$106iO.Od,IN.AbbiTioN`Tq,..tA1 CE)S7.wF:i"oopwsAI°w.1r1 ARAoT <br /> iAr,,PRNEY's FEES,.=P.ANIAGI S:As PROVIDED FOR IN SEGTION.37..PF THE LABOR COV4, <br /> i�ILL 13L . )R:.+d H[5R T�AAN C47�IGNIiAl��PERMIT AATI�N <br /> .,,..,. J <br /> i <br /> ( igne$iire:at` 7 licensed' authori�ni repr$scr>tatiwe),, <br /> hereby aut}torize: int.namej t.1 ti ,.:to segn_.this'�an.Joaquin,. County Wall. l form :Permit <br /> Aopllca#ion an My bt:half. I uhderstand flats.Autiinrividwl fs ualld for.ono yearond:is <br /> :Ilmited'ta:fila WiDrlt <br /> pfan d ecl`bfi tYe i t page of thls.6 Wf ation; <br /> rrto zs u� bo"iz weu P g? <br /> I <br />